Case 248: Cystic Duodenal Dystrophy with Groove Pancreatitis.

History A 59-year-old man presented to the gastroenterology outpatient department with acute abdominal pain centered in the epigastrium. He had experienced similar episodes of abdominal pain in the past that had been treated with surgery. He reported multiple failed attempts at upper gastrointestinal endoscopy. Laboratory tests were performed at the time of admission and revealed a serum glutamic-oxaloacetic transaminase level of 9 U/L [0.15 µkat/L] (normal range, 5-40 U/L [0.08-0.67 µkat/L]), a serum glutamic-pyruvic transaminase level of 34 U/L [0.57 µkat/L] (normal range, 5-45 U/L [0.08-0.75 µkat/L]), a serum γ-glutamyltransferase level of 210 U/L (3.50 µkat/L) (normal range, 10-50 U/L [0.17-0.83 µkat/L]), a serum alkaline phosphatase level of 157 U/L (2.62 µkat/L) (normal range, 30-120 U/L [0.50-2.0 µkat/L]), a serum amylase level of 210 U/L (3.50 µkat/L) (normal range, 30-100 U/L [0.50-1.66 µkat/L]), a serum lipase level of 391 U/L (6.52 µkat/L) (normal range, 13-60 U/L [0.21-1.0 µkat/L]), an α-fetoprotein level of 3.81 ng/ mL (normal range, 0-9 ng/mL), a total protein level of 4.6 g/dL (normal range, 6.0-8.5 g/dL), and an albumin level of 2.6 g/dL (normal range, 3.5-5.2 g/dL). The rest of the laboratory data were unremarkable. The patient underwent erect abdominal radiography, contrast material-enhanced multidetector row computed tomography (CT) of the abdomen with 100 mL of iohexol (300 mg iodine per milliliter, Omnipaque; GE Healthcare, Shanghai, China) followed by combined positron emission tomography (PET) and CT (hereafter, PET/CT) with 6.9 mCi of fluorodeoxyglucose (FDG) and magnetic resonance (MR) imaging of the upper abdomen.

Imaging and Intervention in Internal Carotid Artery Pseudoaneurysm Secondary to Retropharyngeal Abscess.

Vascular complications secondary to retropharyngeal abscess are rarely encountered in the post antibiotic era and include compression of internal carotid artery (ICA), infective arteritis and pseudoaneurysm formation. Post infectious ICA pseudoaneurysm formation is reported predominantly in the paediatric age group and rare in adults. We report a case of retropharyngeal abscess complicated by ICA pseudoaneurysm in an adult successfully managed by endovascular approach.

Radiological and cadaveric study of anatomical safe zone for transoral base of tongue surgery.

The aim of this study is to identify a surgical safe zone in base of tongue surgery. Fifteen Fresh frozen cadavers (30 head and neck regions) were included in the anatomical study. Twenty-two CT-angiogram (CTA) scans of neck were included in the radiological study. Surgical safe zone for base of tongue surgery was studied in cadavers and correlated the same in CTA. Depth of the lingual artery (LA) from the tongue surface and distance of origin of lingual artery from tip of greater cornu of hyoid bone was significantly different when comparing anatomical to radiological study (p < 0.005). On protruded position of tongue, lingual artery appeared more close to the tongue surface and was never encountered posterior to foramen caecum. Preoperative CTA evaluation would over-estimate the depth of LA putting the lingual artery at risk during resection. A surgical safe zone exists posterior to foramen caecum and towards the midline.

Mind the gap: imaging spectrum of abdominal ventral hernia repair complications.

Ventral hernia repair with or without mesh placement is a commonly done procedure. Laparoscopic approach is more preferred than open in recent surgical practice. Complications occur as like any other abdominal surgeries and are dependent on multiple factors. Complications such as collections, adhesions, and related changes are non-specific. Specific complications related to hernia repair include recurrent hernia, mesh infection, mesh migration, and fistula formation. Post inguinal hernia repair chronic inguinal pain is gaining more attention with increasing use of image-guided nerve interventions for symptomatic management. Imaging plays a vital role in defining and delineating the type and extent of complications. Prior knowledge of the surgical indication and technique helps in better imaging interpretation of complications. This article describes the role of imaging in diagnosis of complications in general ventral hernia surgery setting.

Hydropic degeneration of leiomyoma in nongravid uterus: The "split fiber" sign on magnetic resonance imaging.

Extensive hydropic degeneration in uterine leiomyoma is a rare occurrence and is commonly reported in association with pregnancy. It is a close mimicker of malignancy due to rapid growth and atypical imaging appearances. Awareness of the imaging features helps in diagnosis, avoids unnecessary patient anxiety, and hence reassurance especially when encountered in pregnancy. We report two cases of extensive hydropic degeneration of leiomyoma in nonpregnant females with imaging and histopathology correlation. We also propose the "split fiber" sign as a useful magnetic resonance imaging feature for diagnosing this condition.

A rare case of adult ovarian hernia in MRKH syndrome.

Inguinal hernias containing ovary have a documented incidence of 3%. Most of the cases are associated with congenital anomalies of genital tract such as Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. A 20-year-old female presented with primary amenorrhoea, normal secondary sexual characteristics and genetic karyotyping showing 46XX chromosome. On USG abdomen and pelvis examination complete absence of uterus, cervix and vagina was found. Both the ovaries were seen away from normal anatomical location in bilateral inguinal canal without significant complication. MRI study confirmed agenesis of uterus, cervix and vagina; bilateral inguinal hernia with ovaries as contents. Type 1 MRKH syndrome with bilateral ovarian hernias was diagnosed.

Bilateral nasolabial cysts - case report and review of literature.

Nasolabial cyst is a non-odontogenic, extraosseous, soft tissue cyst, commonly unilateral, located in the nasolabial fold. Bilateral nasolabial cysts are of rare occurrence. This case report describes the multimodality imaging appearance of bilateral nasolabial cysts with a review of literature.

Oesophageal perforation as a complication of ingested partial denture.

We report herein the case of a 53-year-old female who came to the emergency room with the chief complaints of severe dysphagia and chest pain following accidental swallowing of her denture. The patient had swelling of the face, neck and eyelids with difficulty in breathing. A skull radiograph was taken, which revealed a missing partial denture from the right lower jaw. Anteroposterior radiograph of the chest showed two metallic objects in the mid-thorax, adjacent to the descending aorta. CT scan of the neck and chest revealed two metallic objects (measuring approximately 17mm each) in the middle one-third of the oesophagus (right posterolateral aspect), causing perforation of the oesophagus and leading to pneumomediastinum, and left pneumothorax with subcutaneous emphysema of the neck and chest. An emergency thoracoscopic removal of the foreign body (partial denture) was performed with subsequent repair of the oesophageal tear in the same sitting. Post surgery, the patient was shifted to intensive care unit and she recovered well over a course of time. In summary, accidental ingestion of a partial denture can lead to grave complications such as oesophageal perforation, which should be managed on an emergency basis with thoracoscopic removal of the foreign body.

Multimodality imaging in adnexal torsion.

Adnexal torsions are one among the causes of acute pelvic pain in females. Commonly occurring adnexal torsions are ovarian either involving the normal ovary with functional cysts or an associated mass. Fallopian tube torsions, torsions involving paraovarian, fimbrial cysts and subserosal fibroids are rare. Here we discuss the multimodality imaging approach for the diagnosis of adnexal torsion, its limitations and mimics.

HRCT evaluation of microtia: A retrospective study.

PURPOSE: To determine external, middle, and inner ear abnormalities on high-resolution computed tomography (HRCT) of temporal bone in patients with microtia and to predict anatomic external and middle ear anomalies as well as the degree of functional hearing impairment based on clinical grades of microtia. MATERIALS AND METHODS: It was a retrospective study conducted on Indian population. Fifty-two patients with microtia were evaluated for external, middle, and inner ear anomalies on HRCT of temporal bone. Clinical grading of microtia was done based on criteria proposed by Weerda et al. in 37 patients and degree of hearing loss was assessed using pure tone audiometry or brainstem-evoked response in 32 patients. Independent statistical correlations of clinical grades of micotia with both external and middle ear anomalies detected on HRCT and the degree of hearing loss were finally obtained. RESULTS: The external, middle, and inner ear anomalies were present in 93.1%, 74.5%, and 2.7% patients, respectively. Combined cartilaginous and bony external auditory canal atresia (EAC) was the most common anatomic abnormality in our group of microtia patients. Hypoplastic mesotympanum represented the commonest middle ear anomaly. The incidence of combined ossicular dysplasia and facial canal anomalies was lower as compared to other population groups; however, we recorded a greater incidence of cholesteatoma. Both these factors can have a substantial impact on outcome of patients planned for surgery. We found no significant association between grades of microtia and external or middle ear anomalies. Similarly, no significant association was found between lower grades of microtia (grade I and II) and degree of hearing loss. However, association between grade III microtia and degree of hearing loss was significant. A significant association between congenital cholesteatoma and degree of pneumatization of atretic plate and mastoid process not previously studied was also recorded in our study.

Giant aneurysm formation in sporadic renal angiomyolipoma.

Angiomyolipomas are the most common mesenchymal renal neoplasms. Two types have been described: (i) sporadic angiomyolipoma and (ii) angiomyolipoma associated with tuberous sclerosis. Giant aneurysm formation is usually noted in angiomyolipomas associated with tuberous sclerosis and is rare in sporadic variety. Tumor diameter and aneurysm diameter have been used as predictors of rupture. We report a rare case of aneurysm formation in a sporadic angiomyolipoma.